Could fluorescence-guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary.

BACKGROUND: Indocyanine green fluorescence vision is an upcoming technology in surgery. It can be used in three ways: angiographic and biliary tree visualization and lymphatic spreading studies. The present paper shows the most outstanding results from an health technology assessment study design, conducted on fluorescence-guided compared with standard vision surgery. METHODS: A health technology assessment approach was implemented to investigate the economic, social, ethical, and organizational implications related to the adoption of the innovative fluorescence-guided view, with a focus on minimally invasive approach. With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaires and self-reported interviews, considering the dimensions resulting from the EUnetHTA Core Model. RESULTS: From a systematic search of literature, we retrieved the following studies: 6 on hepatic, 1 on pancreatic, 4 on biliary, 2 on bariatric, 4 on endocrine, 2 on thoracic, 11 on colorectal, 7 on urology, 11 on gynecology, 2 on gastric surgery. Fluorescence guide has shown advantages on the length of hospitalization particularly in colorectal surgery, with a reduction of the rate of leakages and re-do anastomoses, in spite of a slight increase in operating time, and is confirmed to be a safe, efficacious, and sustainable vision technology. Clinical applications are still presenting a low evidence in the literature. CONCLUSION: The present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an HTA approach, sustains the use of fluorescence-guided vision in minimally invasive surgery, in the fields of general, gynecologic, urologic, and thoracic surgery, as an efficient and economically sustainable technology.

Inferior epigastric artery pseudoaneurysm in a kidney transplant recipient.

Pseudoaneurysm of inferior epigastric artery (IEA) is a very rare clinical entity. We reported a case of combined kidney transplant and pseudoaneurysmectomy in a young HBV-HCV-HIV recipient. This case emphasizes the possibility of planning a safe and correct surgical treatment and the best timing to treat IEA pseudoaneurysm. An exhaustive preoperative radiological study in all patients candidate to kidney transplant could identify the possible aortoiliac disease both stenotic or dilatative even if it is rare and helps to define the best treatment options.

Is the loss of gallstones during laparoscopic cholecystectomy an underestimated complication?

Laparoscopic cholecystectomy entails an increased risk of gallbladder rupture and consequent loss of stones in the abdominal cavity. Herein we report the case of a 51-year-old male patient, who underwent laparoscopic cholecystectomy 2 years before presentation to our hospital. He had experienced tension sensation and epigastric pain since 4 months postoperatively. A well-defined epigastric mass, which was hard and painful on palpation, was detected and later confirmed by ultrasonography and CT scan. Explorative laparotomy revealed a mass in the area of the gastrocolic ligament,resulting from biliary gallstones in conjunction with a perimetral inflammatory reaction. A review of the literature showed that the incidence of gallbladder lesions during laparoscopy is 13-40%. In order to prevent this complication, meticulous isolation of the gallbladder, proper dissection of the cystic duct and artery, and careful extraction through the umbilical access are required. Ligation after the rupture or use of an endo-bag may be helpful. The loss of gallstones and their retention in the abdominal cavity should be noted in the description of the surgical procedure.

Description of new "bowel-sparing" techniques for long strictures of Crohn's disease.

In the period of January 1993 to December 1995 we operated on 55 patients with various complications of Crohn's disease. In properly selected cases, obstructive complications of Crohn's disease can be treated effectively by strictureplasty. Long strictures, even if a narrow lumen is still present, are commonly managed by resection, as classic strictureplasties cannot be done; also Finney strictureplasty seems inadequate, as it creates a blind loop that favors bacterial overgrowth and fecal stasis. Three original "sparing bowel" surgical approaches are proposed as possible alternative in the treatment of long stricture in Crohn's disease. We perform side-to-side ileoileal plasty whenever we are faced with severe narrowing of a long segment of small bowel (>10 cm); side-to-side ileocolic plasty whenever very severe disease with narrowing of ileocaecal valve is present; and ileocaecal plasty when terminal ileitis involves the very distal end of the small bowel, but sparing or only minimally affecting the ileocaecal valve. The above-mentioned procedures are described in detail and the clinical outcomes related to the first 8-patient series of our institution are presented.

[Validity, limitations and indications of intraoperative dosage of parathyroid hormone (I-PTH) in the surgical treatment of primary hyperparathyroidism]. / Validità, limiti ed indicazioni del dosaggio intraoperatorio del paratormone (I-PTH) nel trattamento chirurgico dell'iperparatiroidismo primario.

INTRODUCTION: Recently new methods have been experienced to achieve the best surgical results in complete removal of pathological parathyroid tissue; serum I-PTH (1-84) rapid dosage is the most interesting and reliable method. MATERIAL AND METHODS: In a group of 11 patients with IPP, diagnosed by high levels of I-PTH, total and ionized serum calcium, 7 were paucisymptomatic, 3 presented nephrolityasis, 1 acute pancreatitis and severe hypercalcemic crisis. No MEN were found. A systemic research of all parathyroid glands was always performed, then 10, 20, 30 and any 30 minutes after each parathyroidectomy serum I-PTH rapid dosage was made (rapid IRMA method) until the end of surgical treatment. RESULTS: Eight single adenomas parathyroid were diagnosed, 1 double adenoma and 2 hyperplasia. All patients had high levels of serum I-PTH during pathologic parathyroid removal. The decrement of I-PTH level to 40% 10 min after parathyroidectomy, and 50% after 20 minutes confirmed the efficacy of surgery. DISCUSSION: Intraoperative rapid dosage of I-PTH associated with anatomopathologic results leads to a successful diagnosis and therapy. Sometimes in multiglandular disease serum level of PTH decreases after first parathyroidectomy as in a single adenoma: this underlines the importance of systematic surgical research of all glands in any case. CONCLUSION: In our experience serum I-PTH rapid dosage in IPP would be applied by specialized surgical equipments only in selected patients, such as reoperation or those few cases of first surgical treatment when ectopy is suspected.

Surgical treatment and prognostic variables of hepatocellular carcinoma in 122 cirrhotics.

A 10-year experience in surgical treatment of HCC in 122 cirrhotic patients has been reviewed in order to evaluate: perioperative mortality and morbidity, survival rates and prognostic variables by multiple-logistic analysis. Mortality rate declined from 7% in period 1983-88 to 2% in period 1989-92. Operative complications also decreased from 46% to 30%. The 3-year and 5-year overall survival rates were 42.6% and 23.3%. The 3-year and 5-year survival of patients who died only for HCC was 51.1% and 34.2% and the disease-free survival 30.6% and 19.1%. The good results of overall survival were vanished by the high rate of recurrence (19.1%). Multiple logistic regression analysis for the probability of mortality was significant for satellite nodules (RR 2.437), microvascular infiltration (RR 2.432), tumor size (RR 1.147); the model for the probability of recurrence was significant for microvascular infiltration (RR 2.290), satellite nodules (RR 2.280), lesions number (RR 2.216) and tumor size (RR 1.247).

Linguistic development in a patient with Landau-Kleffner syndrome: a nine-year follow-up.

A longitudinal linguistic analysis of aphasic disorder in a 15-year-old boy affected by Landau-Kleffner syndrome followed since the age of 6 is reported. The phonological, morphosyntactic and lexical levels of verbal deficits have been evaluated by means of collected samples of spontaneous language and a battery of linguistic tests. The clinical course has fluctuated with improvement and worsening of aphasia and epilepsy; at the end of the follow-up the boy was seizure-free and a medium-degree disturbance in language production and comprehension was present. The results of the linguistic evaluation suggest that the aphasic disturbance was related to a deficiency in phonological decoding which leads to phonological, morphosyntactic and lexical disturbances. A temporal relationship between the electroclinical picture and the aphasia has been observed: the persistent improvement in linguistic performances took place only after the disappearance of the seizures and of the EEG epileptic anomalies during sleep.

[Ciclopiroxolamine in the topical treatment of vaginal mycoses]. / La ciclopiroxolamina nel trattamento topico delle micosi vaginali.

We have verified the local activity and tolerance of the antimycotic drug ciclopiroxolamine in an open trial. The study included 34 women suffering from clinically and mycologically diagnosed vulvovaginitis caused by Candida. The therapy consisted of inserting a 100 mg ovule of ciclopiroxolamine once a day for 3 days. The cultural examination was negative in 76.5% of cases at the 1st control after the treatment and in 82.3% of cases at the 2nd control after the treatment. All the considered subjective and objective symptoms showed a highly significant decrease of frequency and intensity. No chemical parameter was modified; only in one patient a very mild side effect was verified.

Relation between CT patterns, clinical findings and etiological factors in children born at term, affected by congenital hemiparesis.

In order to examine if specific findings from CT correlate with specific clinical or neurological findings, 30 children, 5 to 16 years old, born at term, affected by congenital hemiparesis without intellectual impairment, were submitted to neurofunctional and psychological assessment and examined by CT. 28 of the 30 children had pathological CT. Two morphological CT patterns were found: A) Cavity in the cortex and underlying subcortical white matter (11 cases); B) Unilateral ventricular enlargement and paraventricular lesions (17 cases). CT was normal in two cases. In our children, born at term, no statistical correlation between CT patterns and anamnestic data was found as described in other studies, although in the patients with cortical-subcortical lesions, there was a slight prevalence of a history of perinatal complications, and in the patients with paraventricular lesions there was an uneventful history or abnormal pregnancy history. The relation between specific CT patterns (type A and B) and specific clinical dysfunction is not statistically evident, (unless for astereognosis and type A CT pattern). However, the patients with cortical-subcortical lesions showed a slight prevalence of a lower function of the impaired hand, and a higher percentage of an I.Q. of less than 90, than the group with unilateral ventricular enlargement. No relation was found between CT lesional pattern and epilepsy. The absence of correlation between morphological aspects and clinical findings could be explained by the complexity of structural changes and remodelling properties of the central nervous system, following prenatal and perinatal brain damage.

Development of language comprehension in preschool children: a picture identification test in the assessment of the comprehension of grammatical structures.

A language comprehension test based on picture identification was administered to 180 normal children aged between 3 1/2 and 6 years. Of the 20 test items 11 correlated with age and with the development of linguistic abilities. The test is sufficiently discriminant in respect of comprehension of morphological-syntactic structures between the ages of 4 and 6 years.